Lecture 5: Valvular Disorders Part 1 Flashcards
What is the difference between stenosis and regurgitation?
- Stenosis: Doesn’t OPEN properly.
- Regurgitation: Doesn’t CLOSE properly.
Stenosis: harsh, clicky sound
Regurgitation: blowing, whoosh sound
What are the 6 clinical classifications for valvular heart disease?
- Stage A: at risk
- Stage B: mild/mod disease, asymptomatic
- Stage C: severe disease but asymptomatic.
- Stage C1: severe, asymptomatic, normal LV function.
- Stage C2: severe, asymptomatic, ABnormal LV function.
- Stage D: symptomatic
What are the risk factors for valvular heart disease?
- Congenital defects (AS, PS, bicuspid aortic valve)
- Aging
- Infective endocarditis
- Rheumatic fever
What are the two settings AS typically occurs in?
- Congenital: leaflet abnormality (MC: bi), presenting prior to 50yo.
- Acquired: rheumatic fever, valve calcification, degenerative stenosis, presenting after 50yo.
What occurs physiologically in AS and what secondary condition does it typically lead to?
- Thickening and calcification of the valve leaflets.
- Narrowed valve opening
- Often can lead to LVH, leading to diastolic dysfunction and then systolic dysfunction.
AS opens during systole, which is during left ventricular contraction. The LV attempts to squeeze harder to push the blood through a smaller opening.
How does degenerative or calcified AS result from aortic sclerosis?
Aortic sclerosis is calcium deposition on valve leaflets, which will lead to AS.
Most common surgical valve lesion in developed countries.
What are the 3 risk factors for calcified AS?
- HTN
- HLD
- Smoking
AS congenital abnormality image
What are the 3 cardinal symptoms of AS?
- Angina: coronary hypoperfusion (usually exertional)
- Syncope: Increased LV pressure => baroreceptors inducing peripheral vasodilation.
- CHF
|Cardinal AS = CAS
Describe AS on PE.
- Mid-systolic, crescendo-decrescendo
- R 2nd ICS with radiation to carotids
- Medium pitch, harsh quality, often loud with a thrill.
- Best heard sitting and learning forward.
Additional potential findings:
S4 gallop
LVH on EKG
Laterally displaced, sustained apical impulse (if LVH is present)
What is the diagnostic modality of choice for AS and what should we see?
- Echocardiography
- Valve < 1cm2 is severe, esp if mean gradient is > 50mm Hg
AKA smaller valve.
What secondary diagnostic study can confirm the presence of severe AS and any CAD?
Cardiac catheterization
What is the treatment for severe AS with symptoms?
AVR (aortic valve replacement), either through TAVR or open.
Need anticoag as well!!!!
What is the anticoagulation for mechanical valve vs TAVR?
- Mechanical: warfarin +/- asa
- TAVR: 6 months of plavix + lifelong asa
When is balloon valvuloplasty used?
- Congenital AS primarily!
- No medical therapy has been proven to slow progression
What causes aortic regurgitation?
- Aortic leaflets abnormality: rheumatic fever, congenital abnormalities, infective endocarditis, HTN
- Aortic root abnormality: aortic dissection or dilation, Marfan’s
What does chronic AR generally lead to?
LVH and dilation, which eventually leads to HF.
How does AR typically present?
- Asymptomatic for years
- CHF symptoms
- Exertional dyspnea
- Fatigue
- Angina (similar mechanism to AS)
Describe the PE findings of an AR murmur.
- Early diastolic, decrescendo, blowing
- High pitched, best heard in 2nd to 4th L ICS, with radiation to apex.
- Best heard sitting and leaning forward
Additional findings:
Widened pulse pressure
S3 or S4 gallops
Low-pitched diastolic mitral murmur at apex (austin flint murmur)
What is the treatment for symptomatic AR?
- AVR surgery
- Vasodilator therapy (does not slow progression)
What is the primary difference between AR and acute AR?
Body is unable to compensate for the AR, so it is an emergent situation.
What is the life-threatening condition that results from acute AR?
Hemodynamic instability as the LV is unable to compensate for the increasing volume.
Eventually leads to pulmonary edema.
How does acute AR present?
- Cardiogenic shock
- Pale, cool extremities
- Weak, rapid pulse
Murmur will still be present usually, but pitch will be low.
Peripheral pulses will either be weak or absent.
What is the main diagnostic tool for acute AR? What would be expected on diagnostic tests?
- STAT echocardiogram is main diagnostic tool!
- EKG showing mod/sev LVH
- CXR showing cardiomegaly with LV prominence
What are the treatment options for acute AR?
- Vasodilator therapy
- Diuretics
- Might need to add inotropes and vasopressors later.
- Treatment of choice is still urgent AVR.
What is the physiology of mitral stenosis?
Thickening and immobility of the mitral leaflets impedes flow from left atrium to left ventricle.
What is the most common cause of mitral stenosis and what demographic is most common?
- Rheumatic fever.
- 2/3 of cases are generally women
What is the first pathophysiologic change that tends to occur with mitral stenosis?
LA enlargement.
What is the most common cause of right-sided heart failure?
Left-sided heart failure
Backup from the left results in increased pulmonary pressures, which eventually affects the RV.
What happens to the LV as mitral stenosis becomes more severe?
Reduced SV and CO
When do people with rheumatic MS tend to develop symptoms?
4th or 5th decade of life (usually 20-40 yrs post illness)
What are the symptoms of mitral stenosis usually due to?
- Pulmonary vascular congestion
- RV failure
- Afib
What are the most common symptoms of mitral stenosis?
- Fatigue
- Exertional dyspnea
- Orthopnea
- Afib
What is Ortner syndrome?
Compression of the left recurrent laryngeal nerve from a severely dilated LA resulting in hoarseness
Describe the PE findings of mitral stenosis.
- Low-pitched, rumbling, diastolic murmur
- Best hard at apex in left lateral decubitus
- S1 goes from loud to softer as MS progresses
- Opening snap following S2 is typically present
Use bell for low-pitched.
If pulmonary artery pressure increases enough, P2 can be palpable.
P2 = closure of pulmonic valve
A2 = closure of aortic valve
S2 = closure of both
What EKG findings are typical of mitral stenosis?
- LA abnormality
- AFib
- RVH possible
What is the characteristic rheumatic deformity seen on echo for mitral stenosis?
Hockey stick deformity of the anterior MV leaflet.
2/2 to fusion of commisures and tethering of tips.
Maple syrup = hockey stick
What are the treatment options for mitral stenosis?
- Beta blockers (HR control)
- Diuretics (pulmonary relief)
- Severe = refer!
What are the indications for percutaneous balloon valvuloplasty?
- Pliable, noncalcified leaflets and chords
- Minimal MR
- No evidence of LA thrombus
Not definitive for mitral stenosis
What are the primary causes of MR?
- MV prolapse
- LV dilation (Cardiomyopathy)
- Posterior wall MI
- Rheumatic fever
- Endocarditis
Regurgitant blood flow from LV to LA during SYSTOLE.
AKA the mitral valve didn’t close properly, so instead of blood only going to the aorta, its leaking backwards to the LA.
How do most patients with chronic MR typically present?
Asymptomatic and well-compensated until LV systolic dysfunction occurs.
What are the usual symptoms of depressed LV systolic function?
- Fatigue
- Dyspnea on exertion
- Peripheral edema
Describe the PE findings of a MR murmur.
- Holosystolic murmur
- Best heard at apex, with radiation to axilla and back.
- If MVP is present, mid-systolic click may be present.
What EKG changes may occur due to MR?
- LA abnormality, LVH
- AFib
When is coronary angiography indicated for MR?
- Male > 40
- Menopausal woman with RF
What is the medical treatment for MR?
- Afterload reduction via vasodilators (ACE/hydralazine)
- Diuretics for pulmonary symptoms
What is the definitive treatment for MR and when must it occur?
- Surgical intervention
- Must occur prior to irreversible myocyte damage and LV remodeling.
- Need annual echos!
What are the two surgical treatments for MR?
- Mitral annuloplasty (sewing in a prothestic ring)
- Mitral valve replacement (if overly calcified)
Why is acute MR an emergent situation?
Cardiogenic shock due to increased LA pressure without LA dilation.
Pulmonary pressure then increases drastically.
What are the primary causes of acute MR?
- Acute MI (usually posterior wall)
- Trauma
- Endocarditis
- Tachyarrhythmia with chronic MR
- MVP
How does a patient with acute MR present?
- Signs of cardiogenic shock
- Low-pitched, soft murmur in early systole
- Need urgent valve replacement
Who is MVP MC in?
Women
Usually younger and thinner with chest wall deformity.
Can be inherited as autosomal dominant.
What is MVP?
Superior displacement in ventricular systole of one or both MV leaflets across the plane of the mitral annulus towards the LA
Outpouching that does not immediately cause MR.
What are the symptoms of MVP syndrome?
- Chest pain
- Palpitations
- Dizziness
- Anxiety
- Fatigue
Describe the PE findings of MVP.
Mid-systolic click, with late systolic murmur
Why does standing have an earlier MVP click?
Heart compensates by pumping with more force.
What is the treatment for mild MVP without MR?
No intervention.
Need to monitor for progression to MR.
